Background. Since the late 1970s, the U.S. mortality rate from asthma has risen sharply. Because death from asthma is rare, prospective studies have been difficult to perform. Prior hospitalization, especially ICU admission, defines a group at high risk for adverse asthma health outcomes. (1) To evaluate the impact of health care process factors - physician specialty, asthma medications, prescription of self-management plans, and environmental control measures - on health outcomes among high risk adult asthmatics. (2) To elucidate the effect of patient-level characteristics - perceived control of asthma, depression, and asthma severity - on asthma outcomes. To assemble a cohort of adults with severe asthma, we will prospectively study all eligible adult Northern California Kaiser Permanents (KP) members hospitalized for asthma during a 3 Year period (target n=3600). The highest risk patients, following ICU admission for asthma (n=500), will undergo structured telephone interviews. Using both computerized and interview data, we will delineate the factors associated with asthma outcomes: re-hospitalization, urgent health care utilization, and health care cost. The proposed study will elaborate the factors associated with poor longitudinal health outcomes among high risk adults with asthma, identifying targets for clinical and policy interventions. A current NRSA recipient, Dr. Eisner has conducted epidemiologic research in adult asthma during his 2-year postdoctoral research fellowship. The proposed K23 award would provide advanced patient-oriented research training in epidemiology, health outcomes, and biostatistics. The career development plan includes: (1) independently conducting a prospective cohort study (2) formal mentoring from a multi- disciplinary scientific advisory committee (3) advanced didactic training, leading to an MPH degree. This award will enable Dr. Eisner's continued progression to an independent clinical investigator.